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Form Approved.'Ol No,2050-0039 <br /> 4.Manifasl Tracking Number <br /> Plea Se print or pe. Pa 1 of E e cy Rw,parise Ff or; A SKS Q <br /> 1.Generator ID Number $e - t�+"= 'vp' a r S n V <br /> UNIFORM HAZARDOUS t«i+:i'J k i u r c.�-`, f I + <br /> WASTE MANIFEST Generator s Site Address[if different than mailing address) <br /> 5.Generatofs Name and Mailing Address <br /> inaStL3 i`Ia?lc� ^jv'?!'1t zf zt-h r�� <br /> N�d9Cr i'id:1J ,'.1Rw'"k :.aGLi FitGf'k '�•Gai e qt!r 1E40 Na`. y <br /> 1-40 12; �:. At{1'c F11' ' ci f 1I't3 c: <br /> y <br /> 71�fCK l'ON �N 'ter �'-1 r STOCKI l� <br /> i I <br /> E0L f—hf=rG' �3e.� U.S.EPA It7Num ber <br /> Generators Phone: P5 <br /> 6- <br /> 6-T. rerica ame, <br /> 71S iM`.7 <br /> U.S.EPA VD Number <br /> 7.Transporter 2 company Name <br /> [1h;4N Nk.�(IeON •i�rAf L.]4'j IFi U.S.EPA1DNuml!er <br /> 8.Designated Facility Name and Site AddressLty HH <br /> 7�r ��:�° '� �7 f P�t.E: i,i•i :fi t e'ti'4 .-- - <br /> li-MII�IEai 'ia + �.ilv 4 -t <br /> Facility's Phone' 10.Containers 11.Total V.Unit 13.Waste Codes <br /> 9a 9b.U.S.DOT Description{including Proper Shipping Name,Hazard Class,ID Number. No Type Quantity Wt•N(A• <br /> HM and Packing Group(if any)) <br /> "s Vj T'HYLZYCL0PENTASILO7[l <br /> Pb I 1 x <br /> a 2 <br /> w <br /> ca <br /> 3. <br /> I <br /> 4. <br /> Buda <br /> 14-Special Handling instructions aninformal d Additional informon r..r. r <br /> 1bEi la#licaw -leiter t r' r. of <br /> Ei�tEkGttiC k'#9 '-4E�B—:t 7646- :iiir:1 <br /> t.'eiFsa r-rr'�;�r S CTi <br /> DI ]S11C1 I s �TsS or'ter' t❑ add LSC' Si1t]S�iL'l�e ��[1iLsDTidli <br /> er shi in name.and are dassified,packaged, <br /> kcahie international and national governmental egulations.if export shipment and I am the Primary <br /> 15- GEHERATOR'SfoFFE(-aTt CERTIFfCATI�H: i hereby decoke that She contents of th€s consignment are fully and accurately described above by the prop PA 9 <br /> marked and lab6ediplacarded,and are in all respects in proper condition for transport according to appy <br /> f l am a large quantity generator)or(b)(it I am a small quantity generator)is true. Month flay Year, <br /> Exporter,!certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent- <br /> Exporter, <br /> onsen. it <br /> V certify that She waste minimization statement identified in 40 CPR 262.27(a){ Signature <br /> Generatoe OfferroessPPrintedrryped Name <br /> of) �. V <br /> ort U.S. <br /> Port afenirylexil: <br /> from <br /> 1fi.Internacional Shipments Import M U.S. ExpDate leaving U.S.: <br /> 9 Transporter signature(tor exports only); kypnm Day Year <br /> W IT.Transporter Acknowledgment of Receipt of Materials Sign e <br /> Uj <br /> Tra s r 1 PrintedfTyp Name f v �th <br /> Month Day Year <br /> -.'�� SignatureIL <br /> 7 Trans er n tedaype Name <br /> r <br /> �f �G <br /> 18.Discrepancy ❑Type <br /> Residue @arlial Rejection ❑Pull Rejection <br /> ❑ <br /> 1 Ba.Discrepancy indication Space Cuantity <br /> Manifest Referenrz Number U,S.EPA ID Number <br /> i <br />€ � 18h.Alternate Facility <br /> or Generator] <br /> 1 Month Day Year <br /> I [.7 <br /> u FaciillYs Phone' <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> f- recycling stems <br /> j 4. <br /> � L7 19 Hazardous Waste Report Macegement Me' <br /> Cedes{i-e.,codes for hazardous waste treatment,disposal.and rec kn systems) <br /> 2. <br /> d b the manifest except as noted in item 1Be Month Day Year <br /> 20.Designated Fac lily owner or operator Ce0cation of receipt Of hazardous materials coven Y Signature t <br /> PrintediTyped Name j CA,C'n Cj DESIGNATED FACILITY TO GENERATOR <br /> FPA Farm 8700-22(Rev..12-17),, evious editions are obsolete. - - <br />